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Four ways to better track your patients' complexity—and get paid for it

Lately, when I’ve been meeting with health system and medical group leaders about their ongoing EHR issues, I’ve been fielding a couple of interesting questions:

How do we get value from the last several years of investing not just in our physician practices’ EHR, but from our overall investment in the practices themselves?

If we try to fully leverage our physician practices and move to risk-based payment models, how do we make that work given our cash flow needs?

These questions are interesting because—although it’s not a comprehensive strategy—there’s an answer that’s quite simple and can help address the core issues. It’s to better document Hierarchical Condition Categories for your Medicare patients, particularly if they participate in a Medicare Advantage plan.

A quick tutorial on HCC complexity

CMS uses a system of Hierarchical Condition Category (HCC) codes to calculate Medicare Advantage reimbursement and provider performance for those participating in its Hospital Value-Based Purchasing Program. And we are hearing that even private insurers are considering HCCs as a chassis for their own risk-adjustment programs.

HCC codes are assigned to beneficiaries across a year to recognize treatment for medical conditions. Each relevant code relates to an ICD diagnosis and has a weighted measure of the resources required to treat it. Therefore, the more complex and resource-intensive the group of beneficiaries are, the higher the future payments are to the MA plans and providers who serve them.

So reconciling either inaccurate or incomplete documentation of complex conditions now poses a real opportunity for providers to improve both quality of care and adequacy of MA-related payments to providers. You might be thinking “that’s easier said than done,” but we have identified four ways to simplify the task.

Four ways to simplify HCC coding

1. Prioritize your patients’ problem lists
The HCC system may seem complex, but it really boils down to providers doing one thing: keeping problem lists—a portion of the medical chart—up-to-date and comprehensive for every MA patient. For example, if a patient had a heart attack five years ago, it should be on the problem list of that patient’s medical chart.

This level of accuracy supports care, documentation, billing and HCC credit for conditions that impact your risk-adjusted payments. Remember, HCC documentation affects the regular rate CMS pays for MA beneficiaries and not the payment amount tendered for a particular encounter or care episode.

2. Take a baseline reading of your HCC capture
We recommend reviewing the previous year’s billing data and problem lists for your MA patients, keeping a close eye on the following:

Are there items with HCC value in the billing data that aren’t on the problem list for particular patients?

Are there items on the problem list but not in the billing data?

Where do documentation and billing process challenges tend to recur?

Is there clinical data in the EHR that suggests HCC-relevant conditions that haven’t been addressed?

By gathering this data and having a baseline understanding, health system and medical group leaders can then go on to fully quantify their HCC opportunity, and be better positioned to engage key stakeholders and rally support to improve HCC complexity capture.

3. Launch a provider engagement initiativeThe majority of clinicians that we meet don’t fully understand the HCC system of coding and reimbursement. Yet their engagement is crucial to capturing a patient’s full complexity.

Health care leaders need to proactively educate their clinicians around HCCs, and can do so by creating an FAQ that captures what is relevant for them to know—and be sure to frame the work in clinical terms. Additionally, the most resonant messaging tends to highlight cases where a comprehensive problem list facilitated a more effective and personalized care plan for a patient, and the reimbursement then reflected the true complexity of the case.

Another consideration, alongside education, is to include compliant incentives to the providers as well.

4. Embed HCC management tools seamlessly into staff workflowsEven an engaged staff and provider community will be ineffective without the appropriate performance management tools. Without them, decision-makers often lack effective prompting to consider a patient’s history, or take an action that conforms to a care protocol.

Critical information should be accessible to providers at the point of care, allowing them to make more informed decisions without adding "clicks." Organizations that find innovative ways to do this without damaging clinician productivity will realize the biggest gains.

Get more insights from John and our HCC Consulting team

Meet our HCC Capture and Documentation Consulting team to learn how we can help you develop HCC coding competencies and engage clinicians in documentation improvement.